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Surgery
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advancement flap | tissue stretch from sides of wound |
anesthetics, classification | amides: dibucaine hydrochloride (nupercaine), lidocaine aminobenzoate esters: benzocaine, benoxinate hydrochloride, tetracaine benzoic acid esters: cocaine, hxylcaine, piperocaine, proparacaine miscellaneous: cyclomethycaine, dimethisoquin, diperodon, dyclonine, prmoxine |
basic surgical tray | #3 blade handle, Adson 1 x 2 delicate tip forceps, Iris scissors 4 ½ curved serrated, 2 single prong skin hooks, 2 Halstead mosquito forceps 5” curved delicate tips, Webster needle holder 5” smooth jawed with tungsten-carbide inserts, Northbent suture scissors 4 ¾ |
| bleeding | Typical causes; coagulopathy (intrinsic or iatrogenic), inadequate intraoperative hemostasis, loose pressure dressing, exertion and/or manipulation of the wound site by the patient |
Burrow’s triangle | triangle of tissue removed to facilitate rotation flap |
clamp | Chalazion: useful for stabilizing mobile mucosal surfaces |
composite graft | graft of skin and other appendage (hair, cartilage) ex: hair transplant autograft donor sites: antihelix, inferior crus of ear helix, scalp, tragus |
curette | 1-10 mm, round or oval |
dermatomes, electric | Brown (Zimmer): most common Padgett: cumbersome graft width adjustment, because uses shims Simon-Davol: light, but only one setting (0.015 thick and 1 5/16” wide) |
dermatomes, free hand | Blue blade, Weck knife |
digital nerve block | lidocaine without epinephrine, use < 2 cc, may use EMLA |
dog ear | AKA redundant edge tissue, standing cutaneous cone, triangular redundant tissue |
donor site--graft site | superior retroauricular area/upper eyelid--lower eyelid, lower retroauricular area--cheek/temple, preauricular area/lower lateral neck--mid cheek/chin, supraclavicular area-medial canthus/lower eyelid, upper lateral neck--helix, glabella--chin/forehead/nose inguinal fold/antecubital fold--hand, nasolabial fold--nose |
EMLA | eutetic mixture of local anesthetics |
epinephrine | 1:100,000-1:300,000 epi:lidocaine. Controversial (and routinely disregarded): avoid on ears, fingers, nose, penis, toes |
forceps (pickups) | Adson: most common forcep, smooth, serrated, toothed (1 x 2), may have suturing platform Allis: tightly grasping tissue for mobilization (cyst removal) Bishop-Harmon: use for delicate tissue, 3 holes in handle, smooth, serrated, toothed (1 x 2) Brown Adson: 7-8 grasping teeth per side to grasp heavy tissue DeJardin: wide jaws, 8 teeth per side (horizontal) for cartilage Iris: narrow handle, delicate tissue, smooth, serrated or toothed (1 x 2) |
forehead flap | may involve supratrochlear artery |
freer elevator | instrument for use in nail removal |
full thickness skin graft | ex: dog ear graft |
fusiform shape | 3:1 ratio (except on back 1-1.5:1) |
glabellar rotation flap | nose |
gold handles | tungsten-carbide inserts in instruments |
| hematoma | acute/expanding; occurs within hours of surgery; edema, throbbing pain stable; present days after surgery; evolve from amorphous to organized (firm) to liquified (dissolved). |
hemostats (snaps) | Halstead, Mosquito, Jacobsen |
Hibiclens | avoid use around eyes, ear canal (use povodone/iodine) |
| infection | Typical rate in dermatologic surgery is 2-3%. Observed 3-7 days after surgery with increasing erythema, edema, pain, and warmth. Increased risk with contamination, trauma to the tissue, excess tension, presence of dead space. Inadequate post operative wound care, patient colonization with potentially virulent bacteria (Staph aureus, MRSA). |
island pedicle flap | near nasal ala |
kite flap | see island pedicle flap |
margins | BCC: 4 mm dysplastic nevus: 2 mm melanoma: 1 cm nevus: no margin |
methylene blue | dye used to mark tumor margin, orientation |
Mohs micrographic surgery | stepwise tumor removal with microscopic control allowing maximum preservation of normal tissue |
Mohs micrographic surgery, indications | BCC: morpheaform, perineural, recurrent embryonic fusion planes: nasolabial fold, columella, preauricular, postauricular size: > 1 cm head & neck, > 2 cm trunk & extremities tissue conservation: ear, eyelid, genitalia, lips tumor type: malignant fibrous histiocytoma, microcystic adnexal carcinoma, dermatofibrosarcoma protuberans, merkel cell carcinoma miscellaneous: scar carcinoma, immunocompromised |
m-plasty | 30° angle to save tissue |
mucosal advancement flap | no subcutaneous stitches, use silk |
myocutaneous flap | nose |
needle holders | Castroviejo: spring action, rotary clasp, very fine jaws for fine needles, occuloplastic surgery Crilewood: similar to Webster neuro-smooth: similar to Webster Derf: similar to Webster Halsey: similar to Webster Olsen-Hegar: scissors behind jaws for cutting suture Webster: most popular, variable length & fineness |
O to H | eyebrow, rim of ear, (+/-)lip |
O to Z | forehead, chin, large defects |
recurrence, BCC | cryotherapy 7.5%, ED & C 8%, Mohs’ 1%, radiation 9% |
recurrence, recurrent BCC | ED & C 40%, excision 17.4%, Mohs’ 5.6%, radiation 9.8% |
recurrence, SCC | Mohs’ <2cm: 1.9%, >2cm: 25.2% |
rhomboid flap | 120° and 60° angles, rotate around 60° angle |
rotation flap | move adjacent tissue in arc |
scalpel blade | #10 large blade, sharp belly, use for large lesions and thick tissue #11 sharp, pointed blade, use for incision & drainage, sharp angles, close margins #15 most versatile tip #15C similar to #15 with narrower, more sharply tapered tip, use for small lesions or delicate tissue |
scissors | bandage: heavy scissors with bulbous lower blade end to cut bandage Gradle: slightly curved short blade, delicate work iris: most commonly used scissors, used for dissection & undermining Metzenbaum: long handle & blade, useful for tissue undermining LaGrange: deeply curved sharp tips, handles with reverse curve, dissecting deep concave surfaces & removing hair transplant grafts Stevens tenotomy: similar to Gradle with longer blade suture: heavy blades, notch at end aid in suture removal Westcott: spring action, fine tips, eye lid work |
skin hooks (rakes) | Frazier, Guthrie, Lahey |
split thickness skin graft (STSG) | full thickness epidermis & partial thickness dermis ex: pinch graft donor sites: abdomen, anterior thigh, back, buttocks, scalp |
subcutaneous suture | avoid on: ear, eyelid, (+/-)forehead |
suture | absorptive: Vicryl slow absorptive: Maxon, PDS non-absorptive: Proline |
tattoo pigments | blue; cobalt aluminate blue/black; carbon brown; ochre iron oxides green; chromic oxide/chromium sesquioxide light blue; cobaltous aluminate red; cinnabar & vegetable dyes, mercury, mercury sulfide (red cinnabar) yellow; cadmium sulfide |
| terrible tetrad | bleeding, dehiscence, infection, necrosis |
tip stitch | ½ buried mattress suture |
transposition flap | moves across tissue; bilobe, forehead, nasolabial, rhomboid |
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